完全经肛全直肠系膜切除术联合括约肌间切除治疗超低位直肠癌  

Transanal total mesorectal excision combined with intersphincteric resection for ultra-low rectal cancer

作　　者：姚宏伟[1] 陈宁[2] 张志鹏[2] 张忠涛[1] 

机构地区：[1]首都医科大学附属北京友谊医院普通外科,肿瘤侵袭和转移机制研究北京市重点实验室,国家消化系统疾病临床医学研究中心,北京100050 [2]北京大学第三医院普通外科,北京100191

出　　处：《首都医科大学学报》2017年第6期790-794,共5页Journal of Capital Medical University

基　　金：国家科技支撑计划课题(2015BAI13B09);北京市医院管理局临床医学发展专项(ZYLX201504);首都医科大学附属北京友谊医院科研启动基金(YYQDKT2016-5);北京大学第三医院临床重点项目基金(BYSY2016018)

摘　　要：目的探索应用完全经肛全直肠系膜切除(pure transanal total mesorectal excision,pure-TaTME)联合括约肌间切除(intersphincteric resection,ISR)治疗超低位直肠癌术式的安全性及可行性。方法经过术前肠镜、直肠腔内超声及盆腔磁共振(magnetic resonance imaging,MRI)等检查进行评估,筛选出本例超低位直肠癌患者,顺利施行pure-TaTME联合ISR手术:利用肛门牵开器充分显露肛管,直视下完成ISR手术。然后建立经肛手术路径,完全经肛完成pure-TaTME手术,并创建肠道的连续性。结果手术时间350 min,术中出血量200 mL。切除标本长约18 cm,远断端切缘1.0 cm,直肠系膜完整。术后病理报告为直肠高级别锯齿状腺瘤,局灶黏膜内癌变,远近断端及环周切缘阴性;检出淋巴结32枚,未见癌转移。病理分期为p T1N0M0。患者术后恢复满意,术后3d肠道功能恢复,开始进流食,术后第5天进半流食,无感染及吻合口瘘发生。至今随访24个月,大便控制功能良好,未见肿瘤复发转移。结论完全经肛全直肠系膜切除(pure-TaTME)联合括约肌间切除(ISR)治疗超低位直肠癌安全可行,这为低位甚至超低位直肠癌的外科治疗提供了一种可行性选择,但远期效果还需要更多病例进行临床研究来确定。Objective To explore the safety and feasibility of pure transanal total mesorectal excision（pure-TaTME） combination with intersphincteric resection（ISR） for ultra-low rectal cancer.Methods The patient with ultra-low rectal cancer,who had been treated with pure-TaTME and ISR,was screened carefully by colonoscopy,endorectal ultrasound and MRI examination.A purse suture closure of the rectal lumen at the level of tumor＇s inferior edge was done transanally.The cut-line was made vertically to the anal canal at the level of dentate line,and further ISR procedure was performed upright into the pelvic floor.Then pure-TaTME was performed.The specimen was pulled down transanally and removed.A colo-anal anastomosis was made by use of circle stapler.Results The operation time was 350 min and the volume of blood loss was 200 mL.The length of the specimen was about 18 cm with intact mesorectum.The distal resection margin was 1.0 cm below the inferior edge of tumor.The circumferential resection margin（CRM） was negative.The pathological cancer staging was T1 N0 M0.Totally 32 lymph nodes had been retrieved without positive node.The postoperative recovery of patient was good without any evidence of infection and anastomotic leakage.Defecation function was acceptable and no tumor relapse was detected after a follow-up of 24 months.Conclusion The operation of pure-TaTME combined with ISR is safe,which provides a feasible option for thesurgical treatment of the low or ultra-low rectal cancer.The long-term outcome need to be identified by further clinical study.

关 键 词：超低位直肠癌 经肛全直肠系膜切除术 完全经肛全直肠系膜切除术 括约肌间切除术 

分 类 号：R735.37[医药卫生—肿瘤]